Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 820 | TR3 ID: 005010X306

Example 4: Charges Exceed Payments (SHOP) — Initial Payment (Optional) | Payment Type Code: INVOICE

This scenario is for the January 2014 coverage month for a SHOP Only Issuer. Subscriber 1: Jane Smith, Exchange Assigned Subscriber Identifier 777222. Subscriber 2: John Doe, Exchange Assigned Subscriber Identifier 777223. Program: Balancing Amount to bring the BPR02 field to $0.

Jane Smith UF -$25
John Doe UF -$15
Program BAL $40
Net Payment $0

Transmission Explanation

Table 1

ST*820*0001*005010X306~

Beginning of an HIX 820 transaction set, Control Number (0001).

BPR*I*0*C*NON************20140110~

Total payment amount is $0. No payment was made. The date the 820 was created is January 10, 2014.

TRN*3*123456789123457~

The unique remittance identification number (123456789123457).

N1*PE*USINS*FI*121231234~

The payee’s name (USINS) with Tax ID number (121231234).

N1*RM*CMS*58*CMS~

Payer’s name and identifier are both CMS.

PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~

The Payer’s informational contact email (CMS_FEPS@cms.hhs.gov) and telephone number (1-800-267-1515).

Table 2

ENT*1~

Start of detail loop for first detailed payment record.

NM1*IL*1*SMITH*JANE****C1*777222~

The subscriber’s name (JANE SMITH) and Exchange Assigned Subscriber Identifier (777222).

REF*38*12346MD000011222~

Exchange Assigned Qualified Health Plan Identifier (12346MD000011222).

REF*1L*987654~

Issuer Assigned Employer Group Identifier (987654). This indicates the enrollment is from a SHOP exchange.

REF*POL*4567~

Exchange Assigned Policy Identifier (4567).

REF*AZ*PLAN1~

Issuer Assigned Policy Identifier (PLAN1).

REF*0F*SUB123~

Issuer Assigned Subscriber Identifier (SUB123).

RMR*ZZ*UF**-25~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The FFM UF amount for this policy is -$25.

DTM*582****RD8*20140101-20140131~

The coverage period for this transaction (01/01/2014 – 01/31/2014).

ENT*2~

Start of the detail loop for second detailed payment record.

NM1*IL*1*DOE*JOHN****C1*777223~

The subscriber’s name (JOHN DOE) and Exchange Assigned Subscriber Identifier (777223).

REF*38*12346MD000011237~

The Exchange Assigned Qualified Health Plan Identifier (12346MD000011237).

REF*1L*678910~

Issuer Assigned Employer Group Identifier (678910). This indicates the enrollment is from a SHOP exchange.

REF*POL*5678~

The Exchange Assigned Policy Identifier (5678).

REF*AZ*PLAN2~

The Issuer Assigned Policy Identifier (PLAN2).

REF*0F*SUB234~

The Issuer Assigned Subscriber Identifier (SUB234).

RMR*ZZ*UF**-15~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The UF amount for this policy is -$15.

DTM*582****RD8*20140101-20140131~

The coverage period for this transaction (01/01/2014 – 01/31/2014).

ENT*3~

Entity 3 is an example of a transaction at the program level, BAL is a balancing loop which brings the BPR02 Total amount to $0 for NON Payment Method Code types. No policy information (2100 Loop) is provided for program level transactions.

RMR*ZZ*BAL**40~

RMR02 refers to a code list published and maintained by CMS representing the payment type. The Balancing Adjustment (BAL) transaction amount for this payee is $40. This brings the BPR02 total to $0.

DTM*582****RD8*20140101-20140131~

The coverage period for this transaction (01/01/2014 – 01/31/2014).

Table 3

SE*28*0001~

Transaction Set Trailer with segment count (28) and Control Number (0001).